Medical marijuana for urologic chronic pelvic pain
It is generally acknowledged that many patients are not satisfied with the contemporary medical approach to the management of urologic chronic pelvic pain syndrome (UCPPS). Many have turned to marijuana or cannabis because of its strong anecdotal reputation of providing benefit to patients with chronic pain. In a condition in which patients are struggling to cope, the marijuana story appears to offer hope.
What is marijuana?
Marijuana or cannabis contains hundreds of known compounds (421 chemicals and counting), including cannabinoids (more than 60). Delta 9-tetrahydrocannibinol (THC) and cannabidiol (CBD) are the most widely studied to date. THC (the psychoactive cannabinoid) stimulates appetite, reduces post-traumatic stress disease (PTSD) symptoms, and can be used as a sleep aid. CBD (the non-psychoactive cannabinoid) reduces inflammation, relieves anxiety, and reduces seizures. The combination of CBD and THC may act as a muscle relaxant, relieve spasms, reduce nausea, and relieve pain. At least that is the theory.
Painful lessons learned from the UCPPS clinic
We have been prescribing medical marijuana for a number of years and are slowly figuring out how to do this properly. We had no textbook, no manual, and no instructions. The literature did not help us. It was really trial and error, with our patients teaching us the optimal strategies for the use of marijuana in UCPPS. Herein, I share the seven most important lessons we have learned.
Lesson 1: Basic research supports the theoretical use of marijuana
If you prescribe marijuana for your patients with UCPPS, you can be reassured that there are many potential theoretical mechanistic pathways by which marijuana has shown possibilities for benefit in basic science research. These include theoretical analgesic, antiemetic, antispasmodic, anti-inflammatory, antibacterial, relaxant, and anxiolytic properties.
Lesson 2: Clinical research does not provide strong support for the use of marijuana in UCPPS
Unfortunately, there are sparse clinical research studies to support the use of cannabis in UCPPS. In fact, there is almost none and we have to rely on what little clinical evidence is available for the use of marijuana in other chronic pain syndromes. There is at least some literature attesting to the possible benefits of medical marijuana in spastic disorders, PTSD, irritable bowel syndrome, rheumatic diseases, anxiety, depression, sleep disorders, inflammation, and chronic pain. Unfortunately, there is just no solid, long-term data for UCPPS management. The available literature suggests that marijuana can reduce pain by 37%, or a total of 0.5 points on a pain scale of 0–10. Inhaled cannabis results in short-term reductions in chronic neuropathic pain for one in every 5–6 patients treated. But the use of medical marijuana is also associated with known adverse side effects, which include dizziness, dry mouth, nausea, fatigue, somnolence, euphoria, vomiting, disorientation, drowsiness, confusion, loss of balance, and hallucination.
Lesson 3: Marijuana is better than opioids
For patients who are having trouble coping because of pain that has not responded to the standard therapies outlined in this supplement, turning to opioids as the last resort is not usually the best approach. Opioids, at best, offer around a 30% improvement in pain and at worse, offer a paradoxical slow exacerbation in pain intensity. With even minor pain relief comes the possibility of physical or at least psychological dependence to opioids, with desire for further increasing doses with diminished returns. Marijuana has fewer downsides, with the possibility of similar pain relief, better psychological coping, and less chance for addiction and dose escalation.
Lesson 4: Recognize patients at risk
All patients with UCPPS are not candidates for medical marijuana management. Patients with a history of substance abuse, diversion risk, and mood disorders should never be prescribed cannabis as a treatment option. If they decide to use the substance on their own, then it will not be a medical error in judgement, but rather a patient-only decision.
Lesson 5: Patient education is the key to successful use of medical marijuana
Patient education should provide a clear understanding of the benefits (30–40% reduction in pain) and risks of medical marijuana ( Table 1 ). The different modes of administration (oral, smoking, vaporization), must be a part of the teaching process. The advantages and disadvantages of the various routes of administration are described in Table 2 .
Understanding CBD (Cannabidiol) for Back Pain
Cannabidiol, commonly referred to as CBD, is a new and relatively understudied treatment for pain, including back pain. Studies suggest it may help relieve inflammation, which is often a factor in chronic back pain. 1
CBD is available in many forms; topical creams and gels have shown promising results for inflammation and neuropathy, which may make them a good option for back and neck pain. 2
CBD requires more research in order to prove and explain its effectiveness as well as to better understand potential side effects (especially long-term) and potential drug interactions.
What Is CBD?
CBD oil is derived from a plant called cannabis sativa. The plant has over 100 chemical compounds, called cannabinoids, that have a range of effects, including anti-inflammatory and analgesic (pain relieving) qualities.
The cannabis sativa plant has two main varieties that are grown for specific purposes:
- THC content. THC is the compound associated with the “high” feeling of marijuana use.
- Industrial (non-drug) uses. This form of the plant contains trace amounts of THC (less than .03%) and can be used to make paper, clothing, and some building material. This variation of the cannabis plant is called hemp.
While CBD is present in both varieties, many of the CBD products available to consumers are from the hemp plant. CBD does not come with the high or psychogenic effects of marijuana.
Ways CBD Treats Back Pain
Research indicates that CBD may reduce back pain by:
- Reducing inflammation 3
- Combating anxiety, often associated with long-lasting or chronic back pain 4
- Helping with sleep and improving overall state of relaxation 5
Some studies suggest that CBD can have an effect on how an individual perceives pain, but more robust research is needed. CBD is generally considered a full-body treatment, which means that it does not target back pain specifically—except in the case of topical products—but contributes to an overall feeling of relaxation and pain relief.
Advocates of CBD believe it can be used to treat a range of conditions in addition to back pain, such as anxiety-related disorders. 5
Potential Risks and Side Effects of CBD
Cannabidiol, even in high amounts, is generally safe. Side effects from CBD may include:
- Dry mouth
- Low blood pressure
More severe side effects, while rare, include:
- Mental confusion
As with other natural products, there is potential for adverse reactions when taken with other medications, especially those that come with grapefruit warnings, such as certain blood thinners. These warnings indicate that certain medications should not be taken with products containing grapefruit.
CBD use prior to surgery
Before having surgery, all cannabis use, including CBD and marijuana, should be disclosed to the surgeon or anesthesiologist. A recent study suggests that cannabis use may have an effect on medications used to sedate patients. 6